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RECENT changes to private mental health insurance offer the prospect of lower premiums and reduced waiting periods, though the magnitude of these benefits is disputed. Travel and accommodation assistance will now be available to help people from rural and remote areas find mental health care. This is critical because the vast majority of private mental hospital services are provided to people in urban areas.These changes, to be phased in during 2018 and 2019, are welcome. They go some way to countering concerns about the value for money of private mental-health insurance. Among these concerns are limits on the number of programs or treatments covered, gap payments for people on disability pensions, waiting periods and so on.
But the changes also risk reinforcing unwanted models of care. In particular, they could perpetuate Australia’s focus on hospitals as the key location for mental health care.
Hospitals are expensive and generally set up to provide mental health care to those who are most acutely unwell. While hospitals are a critical part of the mental health system, they should be the fail-safe backstop – only necessary once other services have been unable to assist – not the front door.
For hospitals to play this role, Australia needs a vibrant network of community mental health services, providing a mix of clinical, psychological and social services to people with severe, moderate and mild mental illnesses. Currently, if your mental illness is too complex to be treated with ten sessions of cognitive behavioural therapy (offered under mental health care plans) but you don’t yet constitute a danger to yourself or others, your service options are very limited.
Australia’s investment in community mental health services is subordinate to our focus on hospital and ambulatory care provided by public and private hospitals. This is despite good evidence suggesting community services are critical to a balanced approach to contemporary mental health care.
Private hospital mental health care
Around 60 private hospitals provide mental health care in Australia. While the public mental health system is much larger, private hospitals provided almost one-quarter of all overnight hospital stays for mental health care in 2015-16. People go to private hospitals with a range of mental illnesses, but depression and mental health problems associated with alcohol are common.
Private hospitals also provide mental health care as a same-day service. Again, depression, anxiety and alcohol account for around two-thirds of patients.
Private hospitals offer a range of group therapies in areas such as managing depression, anxiety, acceptance and commitment therapy, and addiction therapy, among others. Some services also offer transcranial magnetic stimulation (TMS) for these conditions.
In 2015-16, private hospitals provided 242,563 of these same-day services to 18,585 people. This means that, on average, each person came to hospital about 13 separate days that year. To access such therapies, people are typically required to attend the hospital and be admitted as a same-day patient. Private hospitals charge hundreds of dollars for each admission (the cost varies) and government changes to insurance arrangements are likely to make this more lucrative.
At one level any boost is a good thing. Rates of access to state and territory public mental health services are very low and stuck at around 1.5% of the population. The federal government can point to a recent increase in access to mental health services, due to its A$15 million-a-week investment in the Better Access Program.
This has meant that 2.3 million Australians received Medicare-subsidised mental health-specific services (mostly mental health care plans and psychological therapy sessions) in 2015-16. What we get for this investment is not clear.
An unbalanced system
A key finding of the National Mental Health Commission in 2014 was that Australia’s mental health system was unbalanced. However, the government rejected its call to re-prioritise community mental health care over hospitals.
Community mental health services offer clinical, psychological and social services. These are typically provided by teams including mental health professionals, case managers, psychiatrists, social workers, support workers, occupational therapists, psychologists, drug and alcohol and peer workers.
In addition to managing clinical needs, these teams can help with employment, housing, social inclusion and early intervention. But such teams are rare and getting rarer. Psychosocial support organisations have had their funding transferred to the National Disability Insurance Scheme and are losing precious staff and skills
After the most recently announced changes to private health insurance, the federal health minister, Greg Hunt, was asked why people had to wait until they were sick enough to warrant hospital admission before receiving any help. This is a key question – it’s like waiting until your cancer has spread far enough to qualify for care. This is poor health care and economically inefficient. Critical opportunities to intervene earlier (and more cheaply) are lost.
The minister’s response was to point to an increase in headspace services (now up to 110 sites across Australia) and an A$80 million investment the government promised for psychological and social services.
However, Hunt’s predecessor, Sussan Ley, made it clear the goal of the government’s mental health reforms was a new stepped care approach – a hierarchy of interventions, from the least to the most intensive, matched to the individual’s needs. This would permit people with complex and severe mental illnesses to get the help they need in the community.
At best, headspace offers an introduction to mental health care and brief psychological interventions. It is not set up to provide more complex treatments in areas like eating disorders or addiction.
A common finding of the 30 or so statutory inquiries into Australia’s mental health crisis in recent years has pointed to the urgent need to develop sophisticated specialist mental health services in the community. The latest changes to private health insurance do not foster this development. Instead, they risk reinforcing a 20th-century model of mental health care.
This view is bolstered in the light of the new Fifth National Mental Health and Suicide Prevention Plan, which fails to outline a model of mental health care based on the concept of hospital avoidance.
The mental health system is characterised by fragmentation and an unhelpful focus on who pays, not what works. Minister Hunt has shown here an obvious interest in reform. Australia could build on this for more durable and useful reform by acting on recommendations already made by the National Mental Health Commission.